Sunita’s family in the north Indian village of Mukimpur were given their first toilet in February, one of millions being installed by the government to combat disease. She can’t remember the last time anyone used it.

When nature calls, the 26-year-old single mother and her four children head toward the jungle next to their farm of red and pink roses, to a field of tall grass, flecked with petals, where the 7,000 people of her village go to defecate and exchange gossip.

Only dalits, the lowest Hindu caste, should be exposed to excrement in a closed space, “or city-dwellers who don’t have space to go in the open,” said Sunita, who uses one name, as she washed clothes next to the concrete latrine. “Feces don’t belong under the same roof as where we eat and sleep.”

Sunita’s view reveals one of Prime Minister Narendra Modi’s biggest challenges in combating the world’s biggest sanitation problem, one that costs India 600,000 lives annually from diarrhea and exposes a third of the nation’s women to the risk of rape or sexual assault. With no toilets for half the population, Modi promised to build 5.3 million latrines by the end of his first 100 days in office -- one a second until Aug. 31, according to the Ministry of Drinking Water and Sanitation. Without education, they’ll make little difference.

Irrelevant target

“Targets for construction of toilets are somewhat irrelevant to resolving the sanitation problem,” said Yamini Aiyar, director of policy research group Accountability Initiative in New Delhi. “Building toilets does not mean that people will use them and there seems to be a host of cultural, social and caste-based reasons for that. People need to be taught the value of sanitation.”

Indian police keep watch at the tree where the bodies of gang rape victims were found hanging in Katra Shahadatgunj in Badaun district, Uttar Pradesh, India, on May 31, 2014. For women, heading to the fields alone raises the risk of assault, a danger that gained international attention in May with the two girls raped and hanged from a mango tree after they went to defecate outdoors in Badaun.

In most cases, that isn’t happening. More than half of the country’s sanitation education budget since 1999 hasn’t been spent, according to the Ministry of Drinking Water & Sanitation. In at least five of India’s poorest states, the majority of people in households with a government latrine don’t use it, according to a survey of 3,200 rural households by the Research Institute for Compassionate Economics in the capital.

The government has set Mahatma Gandhi’s 150th birthday in 2019 as its target for achieving “total sanitation,” including access to toilets for all 1.2 billion residents, Finance Minister Arun Jaitley said in his budget speech on July 10. While Jaitley doubled spending on new toilets to 40 billion rupees, the ratio of those funds that can be spent on information, education and communication, remains at 15 percent.

Unused funds

Of the 18.3 billion rupees set aside for that purpose in the past 15 years, only 45 percent has been used, partly because local authorities can’t get more funds until they prove how they spent the previous year’s money and partly because the central government often simply ran out of cash, said Avani Kapur, an analyst with New Delhi-based Centre for Policy Research.

“This often creates a vicious cycle as funds get released in the last quarter or even the last month of the financial year,” Kapur said. “Then it becomes difficult to spend all that money during the same financial year, resulting in a cut in funds the following year.”

While villagers remain ignorant of the dangers, about 100,000 tons of their excrement heads to markets every day on fruit and vegetables, according to Unicef, the United Nation’s children’s fund. Each gram of feces in an open field contains 10 million viruses, 1 million bacteria and 1,000 parasite cysts.

The excrement contaminates groundwater, causing illnesses such as diarrhea and cholera, and deters tourists whose immune systems are at the highest risk from the drug-resistant strains of fecal bacteria, according to the World Bank report.

Workers shunned

About 800,000 Indians worked as feces removers in 2008, often carrying excrement in baskets on their heads, an occupation that causes them to be excluded from parts of society.

For women, heading to the fields alone raises the risk of assault, a danger that gained international attention in May when two girls from the village of Badaun in Uttar Pradesh were raped and hanged from a mango tree after they went to defecate outdoors.

“This vicious, horrifying attack illustrates too vividly the risks that girls and women take when they don’t have a safe, private place to relieve themselves,” said Barbara Frost, the London-based chief executive of WaterAid, a charity that helps poor communities get access to sanitation. “Ending open defecation is an urgent priority.”

India accounts for about 60 percent of the world’s residents without toilets, according to a report released in May by the World Health Organization and Unicef. The country’s 50 percent open defecation rate compares with 23 percent in Pakistan, 3 percent in Bangladesh and 1 percent in China, the report said.

Cultural shift

“The problem has gotten worse with the government thinking this is a supply driven problem,” said Archana Patkar, program manager at the Water Supply & Sanitation Collaborative Council in Geneva. “The problem is that germs are invisible, and so understanding the threat of open defecation is far removed from reality until they are sick and dying. And even then, they don’t really understand.”

Sunita's family toilet and a sign marking the government's construction under their toilet subsidy program in Mukimpur Village in India.

India’s previous government in 2012 created a five-year “Sanitation and Hygiene Advocacy and Communication Strategy Framework” to advise states on how to counter the culture of open defecation, including setting up local education committees.

Health Minister Harsh Vardhan said more needs to be done by government and private agencies to build national awareness of the dangers of poor sanitation.

Granddad’s latrine

“The fact that India’s health administrators failed to spread mass awareness on diarrhea management speaks volumes of the inefficiency of previous programs,” he said in a written statement on July 28.

India spent 2.6 billion rupees in fiscal 2013 on a campaign to help eradicate polio after 44 cases were reported between 2010 and 2011, according to the World Health Organization. In the same year, the nation spent half that amount on education for toilets and sanitation.

Some rural residents are constructing their own latrines. In Saunda, a village of about 6,000 people, 30 miles northeast of New Delhi, 70-year-old Hemraj Kumar sits on a cot near his new, 12,000-rupee, porcelain toilet.

“My son built it for me,” he said, wearing a tattered white shirt, as cows tethered to trees defecated in the space between him and the concrete cubicle. “It’s because I can’t walk all the way out into the fields.”

The rest of the family still prefer to head to the mustard field, including Hemraj’s 20-year-old grandson Sonu, who’s studying engineering in college.

’Clean’ villages

Saunda is among 7,971 villages -- about 1 percent of India’s total -- labeled “clean” by the government in the year ended in March.

With little access to running water, government latrines typically consist of a large, concrete septic tank with a ceramic squat-toilet on top, enclosed by a cement or brick cubicle with a narrow door. The government says it has built 138 toilets in Mukimpur since February.

Sunita finds them disgusting.

“Locking us inside these booths with our own filth? I will never see how that is clean.” She points to the field. “Going out there is normal.”